The death of Olympic champion sprinter Tori Bowie from complications of childbirth cast a spotlight on the high rates of maternal mortality in the U.S., particularly among Black women. Far from an anomaly, her death highlights the fact that Black women in the U.S. are three times more likely to die from pregnancy-related causes than white women.
Global data show that the U.S. maternal mortality rate continues to exceed that of other high-income countries. Even more striking, maternal mortality rates among the highest-income Black women are just as high as for low-income white women.
Multiple factors contribute to this racial disparity, including implicit bias, mistrust of the medical community due to past mistreatment, variation in healthcare quality, underlying chronic conditions, and structural racism. Social determinants of health also play a role, preventing many people from racial and ethnic minority groups from having fair opportunities for economic, physical, and emotional health.
To address the multiple challenges of maternal mortality and related disparities, a multidisciplinary team of physician leaders, certified midwives, and nurse leaders in Georgia created an innovative perinatal program. The Cocoon Pregnancy Care Program was developed to improve the quality of care mothers receive before, during, and after pregnancy, while also addressing socioeconomic and healthcare access issues.
As described in a New England Journal of Medicine Catalyst case study, the team in Georgia moved up the initial postpartum visit from the traditional 4 to 6 weeks after birth to 7 to 10 days after hospital discharge. This improved screening rates for postpartum complications in all patients from 46% to 85%, and in high-risk patients from 57.5% to 94.3%. Newer modalities like telehealth, remote monitoring, and psychosocial support also contributed to improvements in key quality and safety metrics, and patients benefitted from a coordinated care team of primary, maternal, and specialty care physicians, dietitians, behavioral health clinicians, nurses, social workers, and other staff.
While implementing innovative perinatal programs like the Cocoon model and others can be critically important, physicians, health systems, patient advocates, and government leaders should also do more to address the underlying causes of the disproportionately high maternal mortality rates for Black women and other underrepresented populations.
Here are six practices to improve the quality of perinatal care:
Acknowledge personal bias. Physicians and other healthcare staff should ask themselves, “What is my bias? Why do I have this bias and what can I do about it? How could this bias perpetuate disparities or lead to other harms?” Ignoring such bias can perpetuate disparities and cause awkward interactions with patients, who can sense discomfort, leading to an erosion of trust. Conversely, patients can sense when a physician sees them without judgment.
Improve cultural humility in healthcare. There has been a shift in healthcare away from the concept of “cultural competency” and toward “cultural relevancy” or even “cultural humility.” The latter acknowledges the impossibility of competency in all cultures and recognizes that this does not diminish respect for the patient or the patient’s perspective. Practicing cultural humility requires us to reflect on our assumptions and demonstrate a respectful willingness to learn. It can also involve recognizing long-standing power imbalances in healthcare, and relinquishing of power by acknowledging that patients are the experts on their cultural identities. Cultural humility can build trust and help patients realize that we ask questions to understand what is going on so we can help them live their healthiest lives.
Diversify the healthcare workforce. Underrepresented communities should see themselves reflected in diverse healthcare teams, physicians, and leadership. Healthcare institutions must also commit to eliminating inequities and continue to champion diversity, inclusion, and equal opportunity in both healthcare and education.
Ensure access to quality care. Hypertension, and other chronic diseases associated with increased risk for pregnancy-related mortality, are more prevalent and less well controlled in Black women. Access to quality primary and specialty care during preconception, pregnancy, and the postpartum period play a critical role in identifying and managing chronic conditions. Also, studies have suggested that Black women are more likely than white women to receive obstetric care from hospitals that provide lower quality of care. Hospitals and health systems can address such disparities by implementing quality improvement protocols and training to consistently deliver high-quality care.
Screen for and incorporate social determinants of health. A significant percentage of a person’s health outcomes — upwards of 70% according to some research — is driven by social determinants of health such as access to food, housing, and transportation. Many health organizations now screen for social determinants of health and connect patients with social services. However, a 2019 study found that just about one-quarter of U.S. hospitals and 16% of physician practices self-report screening for social determinants of health. More health systems should screen for key social needs and connect patients to appropriate services.
Address systemic factors that contribute to pregnancy-related morbidity and mortality. Gaps in healthcare coverage and preventive care contribute to pregnancy-related deaths. Unfortunately, Black women living in socioeconomically challenged zip codes are more likely to lack access to women’s health facilities and high-quality pre- and postnatal care. Moreover, Black women are over-represented in low-paying service sector jobs, which were the hardest hit during the COVID-19 pandemic. Low-paying employment often lacks robust medical coverage, if it is provided at all. Without medical benefits, these workers may not seek preventive maternal care, resulting in worse health outcomes. Fortunately, more than 30 states have already begun to extend the Medicaid postpartum coverage period from just 60 days postpartum to 12 months, and some have also increased eligibility levels. Additional efforts to expand coverage and improve access to maternal care in community clinics can help reduce disparities.
We can remember and honor Bowie as both a track and field champion and as a symbol for Black maternal health. To take the baton and move the cause forward, the U.S. healthcare sector needs to address the health crisis of disproportionately adverse pregnancy outcomes among Black women. Just as critically, healthcare industry leaders need to address the historical legacies of bias as well as the structural and social determinants that contribute to maternal health disparities.
Nkem Chukwumerije, MD, MPH, is president and executive medical director for the Southeast Permanente Medical Group and serves as the Permanente Federation’s national leader for equity, inclusion, and diversity.
